Car Seat Donation Intake Form

Donor Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Pickup or Drop-off Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Car Seat Brand

Car Seat Model Name/Number

Car Seat Manufacture Date (found on the label, MM/YYYY)

Car Seat Condition

Has the car seat ever been involved in a car accident?

Are all parts and accessories included (harness, straps, padding, manual)?

Has this car seat been recalled?

Upload photos of the car seat (including label and all sides)

Additional Comments or Notes